EMPLOYMENT APPLICATION

GENERAL

NAME (Last) (First) (Middle Initial) / TELEPHONE (Area Code)
OTHER NAMES USED
PRESENT ADDRESS
ARE YOU AUTHORIZED TO WORK IN THE UNITED STATES?
q  YES
q  NO / ARE YOU AT LEAST 18 YEARS OF AGE?
q  YES
q  NO / IF NOT, DO YOU HAVE A WORK PERMIT?
q  YES
q  NO
HOW WERE YOU REFERRED TO BOYS & GIRLS CLUBS OF AMERICA (BGCA)?
PREVIOUS EMPLOYMENT WITH BGCA (If any, give dates, position, location)
RELATIVES EMPLOYED BY BGCA (If any, give dates, positions)
HAVE YOU BEEN CONVICTED OF, PLEAD GUILTY TO, AND/OR PLED NOLO CONTENDRE TO A CRIME (FELONY OR MISDEMEANOR, INCLUDING BUT NOT LIMITED TO SEXUAL OFFENDER CRIMES, THEFT, BANKING FRAUD, DRUG AND/OR ALCHOHOL-RELATED OFFENSES, ASSAULT, ETC.)? If yes, please explain (state, date, court, type of crime, place of occurrence, disposition):
q  YES ______
q  NO
Note: Conviction of a crime will not necessarily disqualify you for employment. Each conviction will be judged on its own merit with respect to time and job relatedness.

POSITION APPLIED FOR

TITLE OR CATEGORY SALARY REQUIREMENTS
DATE AVAILABLE WILLINGNESS TO TRAVEL? (Approximate percentage if position indicates)

EDUCATION

SCHOOL / NAME AND LOCATION / MAJOR / GRADUATE
YES NO / DEGREE
HIGH SCHOOL
COLLEGE OR
UNIVERSITY
OTHER SCHOOLS
(Graduate, technical, business, military, etc.)

WORK EXPERIENCE

Start with current or last employer first. Do not detail duties and responsibilities if described in attached resume.
COMPANY NAME YOUR TITLE
COMPANY ADDRESS (Street & No.) (City) (State) (Zip)
START DATE END DATE STARTING SALARY LAST SALARY
SUPERVISOR'S NAME SUPERVISOR'S TITLE TELEPHONE MAY WE CONTACT EMPLOYER?
q  YES
q  NO
BRIEF DESCRIPTION OF DUTIES & RESPONSIBILITIES
REASON FOR LEAVING
COMPANY NAME YOUR TITLE
COMPANY ADDRESS (Street & No.) (City) (State) (Zip)
START DATE END DATE STARTING SALARY LAST SALARY
SUPERVISOR'S NAME SUPERVISOR'S TITLE TELEPHONE MAY WE CONTACT EMPLOYER?
q  YES
q  NO
BRIEF DESCRIPTION OF DUTIES & RESPONSIBILITIES
REASON FOR LEAVING
COMPANY NAME YOUR TITLE
COMPANY ADDRESS (Street & No.) (City) (State) (Zip)
START DATE END DATE STARTING SALARY LAST SALARY
SUPERVISOR'S NAME SUPERVISOR'S TITLE TELEPHONE MAY WE CONTACT EMPLOYER?
q  YES
q  NO
BRIEF DESCRIPTION OF DUTIES & RESPONSIBILITIES
REASON FOR LEAVING

\

Can you perform this job (as detailed verbally or in the job description) with or without reasonable accommodation?

______

______

AUTHORIZATION TO RELEASE EMPLOYMENT REFERENCE INFORMATION

I understand that Boys & Girls Clubs of America (BGCA) will attempt to verify statements made on my application and made during my employment interview. I hereby give my permission for my former employers to answer any and all questions based upon information available to them in my prior employment records. I understand that it is possible that my prior employment records may not be accurate. Nonetheless, in consideration of BGCA’s review of this application and my candidacy for employment, I release BGCA and all former employers from any liability as a result of the furnishing and receiving of this reference information. I understand that my failure to sign this reference release so BGCA can contact references and make a full background check of my previous work history will be deemed interference with and a withdrawal of my application for employment.

____ *Yes ____ *No (*Place your initials in the appropriate space to indicate and document your consent to this authorization.)

Signature ______Date ______

JOB APPLICANT AGREEMENT

I understand that Boys & Girls Clubs of America (BGCA) requires certain information about me to evaluate my qualifications for employment and conduct its business if I become an employee. I understand that false, incomplete, or misleading statements on this application may be considered sufficient cause for rejection of my application and for dismissal, if discovered after I am employed by BGCA. The use of this application blank does not indicate there are positions open and does not in any way obligate BGCA.

I also authorize BGCA to supply information about my employment record, in whole or in part, in confidence to any prospective employer, government agency, or other party having a legal and proper interest, and I hereby release BGCA from any and all liability for its providing this information. I understand that I have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of this investigation.

In consideration of my potential employment, I agree to conform to the rules of BGCA. I understand that I have the right to terminate my employment at any time with or without notice, with or without cause, and that BGCA has a similar right. I understand my employment by BGCA does not constitute a guarantee that any position be continued for any length of time or that any job assignment or shift be permanent.

I understand that I may be required to work scheduled and unscheduled overtime and scheduled weekend and holiday work when required by BGCA. I also understand that BGCA has the right to modify its policies without giving me any notice of the changes. No promises regarding employment have been made to me.

I understand that no one other than the President of BGCA has authority to make any other agreement.

The Immigration Reform and Control Act of 1986 requires that, after employment, employers verify the legal work authorization and identity of all new employees. An offer of employment will depend upon BGCA’s ability to verify this necessary information.

Applications will not be considered active after the position is filled. I understand that BGCA will attempt to verify statements made on my application and made during my employment interview.

______

Signature Date

EQUAL OPPORTUNITY EMPLOYER: Qualified applicants receive consideration for employment without discrimination because of age, sex, religion, marital status, race, color, creed, national origin or disability.